{"id":597,"title":"HEALTH CLAIM FORM","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/health-claim-form","sha256":"50d8197638a52c1606ecf6c505179bcdf54060bf7560fab591bf9a7b41e32770","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim health insurance benefits from IndusInd General Insurance Company Limited. The insured fills the form with details about the policy, hospitalization, and claim.","notes":["Fill the form in BLOCK LETTERS.","The issuance of this form is not an admission of liability.","Attach original documents only.","Use self-attested copies where specified.","Refer to the notified hospital list on the insurer's website; claims from non-notified hospitals will not be entertained.","For claims above ₹1 lakh, PAN card or Form 60 copy is mandatory; below ₹1 lakh, photo identity proof is mandatory.","Attach CTS 2010 compliant cancelled cheque or passbook/bank statement with required details for NEFT payments.","If the policy is on installment basis, balance installments will be deducted from claim amount.","The RTGS/NEFT facility activates within 15 days of receipt of mandate form.","The customer may terminate RTGS/NEFT facility with 15 days prior written notice to the corporate address."],"title":"HEALTH CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Part A - To be filled by Insured","fields":[{"help":"","type":"text","label":"Type of Claim:","options":[],"required":null,"pdf_field":""},{"help":"Enter your policy number exactly as on your policy document","type":"text","label":"*Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Name of the insured person for whom the claim is made","type":"text","label":"*Name","options":[],"required":true,"pdf_field":""},{"help":"Enter age in completed years","type":"number","label":"Present completed age (in years)","options":[],"required":null,"pdf_field":""},{"help":"Specify your relationship to the policyholder","type":"text","label":"Relationship with the Policy Holder","options":[],"required":null,"pdf_field":""},{"help":"Enter your health card or UHID number","type":"text","label":"*Card / UHID No.","options":[],"required":true,"pdf_field":""},{"help":"Full current address","type":"text","label":"*Current Residential Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Select if you want to update your contact details","type":"choice","label":"Change of the contact Details","options":["Yes, I wish to change my contact details","There is no change in my contact details"],"required":null,"pdf_field":""},{"help":"Enter your mobile number","type":"phone","label":"*Mobile Number","options":[],"required":true,"pdf_field":""},{"help":"Select or specify your profession or source of income","type":"text","label":"Profession/Occupation","options":["Business","Profession","Salary","Savings","Agricultural Income","Others"],"required":null,"pdf_field":""},{"help":"Enter your area's postal PIN code","type":"number","label":"*PIN Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Select your sum insured range","type":"amount","label":"Sum Insured `","options":["Upto ` 20,000","` 20,001 to ` 50,000","` 50,001 to ` 1,00,000","` 1,00,001 and above","Others"],"required":null,"pdf_field":""},{"help":"Select your gender","type":"choice","label":"Gender:","options":["M","F"],"required":null,"pdf_field":""},{"help":"If applicable, enter your group or company name","type":"text","label":"Group/Company Name (for Group Health Policies)","options":[],"required":null,"pdf_field":""},{"help":"Select if this policy is a renewal","type":"choice","label":"Is this a renewal policy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter your agent or sub-agent's name","type":"text","label":"Agent/Sub Agent Name","options":[],"required":null,"pdf_field":""},{"help":"Enter agent's mobile number","type":"phone","label":"Agent Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter agent's email address","type":"email","label":"Agent Email ID","options":[],"required":null,"pdf_field":""},{"help":"Enter previous policy number if renewal","type":"text","label":"If Yes, previous year's policy no","options":[],"required":null,"pdf_field":""},{"help":"Select your policy type","type":"choice","label":"Policy Type:","options":["Hospitalization","Pre & Post Hospitalization","Health Check up","OPD","Individual","Group"],"required":null,"pdf_field":""},{"help":"Indicate if pre-authorization was obtained","type":"yes-no","label":"Pre Authorization obtained Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select your monthly income range","type":"choice","label":"Monthly Income","options":["Upto ` 20,000","` 20,001 to ` 50,000","` 50,001 to ` 1,00,000","` 1,00,001 and above","Others"],"required":null,"pdf_field":""},{"help":"Enter your PAN number","type":"text","label":"PAN No.","options":[],"required":null,"pdf_field":""},{"help":"Enter your email address","type":"email","label":"*Email ID","options":[],"required":true,"pdf_field":""},{"help":"Enter your member or employee ID if applicable","type":"text","label":"Member ID No. / Employee ID / Client ID","options":[],"required":null,"pdf_field":""},{"help":"If you have other health insurance, enter company name","type":"text","label":"Name of the Insurance Company","options":[],"required":null,"pdf_field":""},{"help":"Policy number of other insurance if any","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Start date of other policy","type":"date","label":"Policy Start Date","options":[],"required":null,"pdf_field":""},{"help":"End date of other policy","type":"date","label":"Policy End Date","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under other policy","type":"amount","label":"Sum Insured `","options":[],"required":null,"pdf_field":""},{"help":"Indicate if you have other health insurance","type":"yes-no","label":"8. Does the claimant have health insurance policy with any other insurance company?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of main policyholder","type":"text","label":"7. Name of the Policy Holder (Self / Main Member)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Hospitalization Details","fields":[{"help":"Name of the insured person","type":"text","label":"Name of the Insured","options":[],"required":null,"pdf_field":""},{"help":"Date admitted to hospital","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Date discharged from hospital","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Describe illness or injury","type":"text","label":"Diagnosis / Nature of disease / illness contracted / injury suffered","options":[],"required":null,"pdf_field":""},{"help":"Date when injury or illness was first noticed","type":"date","label":"Date of injury sustained or disease / illness first detected","options":[],"required":null,"pdf_field":""},{"help":"Name and address of hospital or nursing home","type":"text","label":"Details of the Hospital / Nursing Home in which treatment was taken :","options":[],"required":null,"pdf_field":""},{"help":"Hospital name","type":"text","label":"Name of the Hospital / Nursing Home","options":[],"required":null,"pdf_field":""},{"help":"Hospital address","type":"text","label":"Address of the Hospital / Nursing Home","options":[],"required":null,"pdf_field":""},{"help":"City of hospital","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Hospital contact number","type":"phone","label":"Telephone / Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of Treating Physician / Surgeon","options":[],"required":null,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Doctor's contact number","type":"phone","label":"Telephone / Mobile Number","options":[],"required":null,"pdf_field":""},{"help":"Fill amounts for each bill head: Room Rent & Nursing Charges, Doctors Consultation/Visit Charges, Investigation Charges (Includes Radiology and Pathology Reports), Surgeon and Assistant Surgeon Charges, Anesthetist Charges, Operation Theater Charges, Medicine Charges (Includes Ward and OT Medicines and Consumables), Taxes/Surcharges/Service Charge, Miscellaneous/Other Charges (like Admission, Registration, etc.), Pre Hospitalization Bills (If Any), Post Hospitalization Bills (If Any), Total Claimed Amount (Sum of all)","type":"table","label":"Details of the amount claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Documents to be attached","fields":[{"help":"Tick if claim form is attached","type":"yes-no","label":"Claim form Duly Filled","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick if authorization form is attached","type":"yes-no","label":"Authorization Form","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick if medicine bills and prescriptions are attached","type":"yes-no","label":"Medicine/Pharmacy Bills with Doctors Prescription","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick if investigation reports are attached","type":"yes-no","label":"Investigation Reports/Reports Name","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick if discharge summary is attached","type":"yes-no","label":"Discharge Summary","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick if implant invoice is attached","type":"yes-no","label":"Implant Name and Invoice (If any)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick if hospital bills are attached","type":"yes-no","label":"Hospital Bills","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick if indoor case papers are attached","type":"yes-no","label":"Indoor Case Papers (duplicate copy)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick if payment receipt is attached","type":"yes-no","label":"Hospital Payment Receipt","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick if photo ID proof is attached","type":"yes-no","label":"Photo Identity Proof","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter total number of pages of documents attached","type":"number","label":"Total No. of Pages enclosed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Policyholder Bank Details","fields":[{"help":"Name as per bank account","type":"text","label":"14. Name of the Bank Account Holder","options":[],"required":null,"pdf_field":""},{"help":"Enter your bank account number","type":"text","label":"15. Bank Account No.:","options":[],"required":null,"pdf_field":""},{"help":"Select account type","type":"choice","label":"16. Account:","options":["Saving","Current"],"required":null,"pdf_field":""},{"help":"Bank name","type":"text","label":"17. Name of the Bank","options":[],"required":null,"pdf_field":""},{"help":"Bank branch","type":"text","label":"18. Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter MICR code from cheque","type":"text","label":"19. MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank)","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code from cheque","type":"text","label":"20. IFSC Code (11 character code appearing on your cheque leaf)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Payment Option by Aadhaar Card (For Reimbursement claims)","fields":[{"help":"Enter Aadhaar number and attach self-attested copy","type":"text","label":"Aadhaar Card No.:","options":[],"required":null,"pdf_field":""},{"help":"Tick to opt for Aadhaar linked bank account payment","type":"checkbox","label":"I wish to collect claim reimbursement directly in my Bank account linked with my aforementioned Aadhaar Card.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by Insured","fields":[{"help":"Sign and date the declaration","type":"signature","label":"I/We hereby declare that the details given above are true and correct to the best of my belief and knowledge.","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Part B - To be filled by the Treating Doctor","fields":[{"help":"Date of first consultation before hospitalization","type":"date","label":"Date of First Consultation (Prior to Hospitalization)","options":[],"required":true,"pdf_field":""},{"help":"Describe patient's complaints on admission","type":"text","label":"With what complaints was the patient admitted for","options":[],"required":true,"pdf_field":""},{"help":"Provide past illness history and duration","type":"text","label":"Detail history of past illness with duration","options":[],"required":true,"pdf_field":""},{"help":"Specify disease or surgery complication if applicable","type":"text","label":"If, yes please specify the disease (OR) complication of any previous surgery done ?","options":[],"required":null,"pdf_field":""},{"help":"Indicate if disease is congenital","type":"yes-no","label":"Whether the disease / disorder is congenital in nature ?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if congenital","type":"text","label":"If yes please specify the details","options":[],"required":null,"pdf_field":""},{"help":"Describe surgery or treatment given","type":"text","label":"Nature of surgery / treatment given for present ailment","options":[],"required":true,"pdf_field":""},{"help":"Enter total inpatient beds including ICU","type":"number","label":"Number of in-patient beds in the hospital (including ICU)","options":[],"required":true,"pdf_field":""},{"help":"Date of doctor's signature","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Doctor to sign and stamp","type":"signature","label":"Doctor's Seal and Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor"}],"deadlines":[],"applies_to":"health insurance claims under individual and group health policies","attachments":["Claim form Duly Filled","Authorization Form","Medicine/Pharmacy Bills with Doctors Prescription","Investigation Reports/Reports Name","Discharge Summary","Implant Name and Invoice (If any)","Hospital Bills","Indoor Case Papers (duplicate copy)","Hospital Payment Receipt","Photo Identity Proof","Self attested Aadhaar card copy (if opting for Aadhaar payment)","Original cancelled cheque","Copy of PAN card"],"declarations":["The details given are true and correct to the best of the claimant's knowledge.","The claimant agrees to provide additional information if required.","The claimant agrees to indemnify the company for any loss arising from misstatements.","The claimant agrees not to receive any rebate other than as per the published prospectus.","The claimant understands that payments will be made only through electronic mode as per IRDAI.","The claimant agrees to refund any excess amount credited in error within 7 days.","The claimant agrees to the terms and conditions of RTGS/NEFT payment facility.","The claimant agrees that claim payment will be credited after confirmation from bankers."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"services@indusindinsurance.com","label":"Health Insurance Claims Email","level":1,"hours":null,"applies_to":"health","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"nce Claim\nTravel Insurance Claim\nCommercial Insurance Claim\nSupport\nSign In\nSelf Help\nVideo Chat\nContact Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"indusind@europ-assistance.in","label":"Travel Insurance Claims Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail:\nindusind@europ-assistance.in\nMobile Application:\nIndusInd Insurance App\nWebsite:\nOnline Claim Intimation\nOffline Visit:\nLocate your nearest branch\nh","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+91 22 48903009","label":"Car Insurance Claim Intimation","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.indusindinsurance.com/car-insurance-claim","quote":"Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185 (Senior Citizen)\n+91 7400422200 (WhatsApp)\n+91 22 48903051 (Become our Partner)\nVisit us:","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934189","label":"Motor Claims Helpline","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.indusindinsurance.com/car-insurance-claim","quote":"ation.\nNeed Guidance on Car Coverage?\nTalk to Our Professional Advisors\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nSteps to Take After a Car ​Accident\nThe following steps can expedite the road accident insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934188","label":"Health Claims Helpline","level":null,"hours":null,"applies_to":"health","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"your nearest location.\nExpert health advice you can trust\nGet in touch with our team today!\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nCommon Reasons for Health Insurance Claim Rejection\nIncomplete Documentation","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934184","label":"Travel Claims Helpline","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"e you can trust\nGet in touch with our team today!\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nCommon Reasons for Health Insurance Claim Rejection\nIncomplete Documentation\nYour claim gets rejected when you don't gi","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+912248903009","label":"Inland Travel Helpline","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"rds your registered bank account.\nHow to Contact Us For Travel Insurance Claim?\nContact Details\nInland Travel Helpline:\n+912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 552","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"91-22-67347843","label":"International Travel Helpline (abroad)","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"For Travel Insurance Claim?\nContact Details\nInland Travel Helpline:\n+912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 209 5522","label":"International Travel Helpline (in India)","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail:\nindusind@europ-assistance.in\nMobile Application:\nIndusInd Insurance","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/indusind-general-insurance/597-health-claim-form"}